209 Norma Lane Lot 23P rmittee's VIE COUNTY HEALTH DEPARTMENT ��' ""� �-- ���
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Name! •�–�,.'�.�'���--j�' Environmental Health Section PROP RTY 3INFORMATION
!l , P.O. Box 848
Directions to property: r �` . �A r'{1 ' /"f't 1 i'
<, L— Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760 a'
s�n �� �`%�� ;% %r��✓ Section: Lot:
AUTHORIZATION FOR �( y
WASTEWATER Tax Office PIN:O. r Z
SYSTEM CONSTRUCTION
AUTHORIZATION NO: -' A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTA HEALTH SP CIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 0 o # BEDROOMS,_ # BATHS #OCCUPANTS --�/ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY �/) DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK/"GAL. TRENCH WIDTH J Ln ROCK DEPT � % LINEAR FT. `rl�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT�%�,{� G
SYSTEM INSTALLED By:,6a
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AUTHORIZATION NO. 70 OPERATION PERMIT BY:DATE: VXV
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DOW 02/02 (Revised)
I3eritt�ttee'� VIE COUNTY HEALTH DEPARTMENT w
'}�NaWt ��� .;� Jt � ��� jTa Environmental Health Section PROP RTY INFORMATION
,,P.O. Box 848
Directions to, property: ��r �) ti 1�locksville, NC 27028 Y _ -Subdivision Name: ��►�/ f+� /�
Phone #: 336-751-8760,
Section: Lot:. 1
~ AUTHORIZATION FOR �, L
WASTEWATER Tax Office PIN:#50 ('� �.
SYSTEM CONSTRUCTION
AUTHORIZATION NO: A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen -nits. This FornVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SP CIALIST DATE
RESIDENTIAL SPECIFICATION: BUILDING TYPE A- # BEDROOMS ,,' # BATHS # OCCUPANTS 4,/ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPjE- # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY t (1 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL.' PUMPTANK�GAL. TRENCH WIDTH (.? ROCK DEPTH,,; LINEAR FT., '
OTHER
i
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT /� e
SYSTEM INSTALLED BY�/ : !Suq,7u�/
r7 �v
11 0 r (�
AUTHORIZATION NO. OPERATIdN PERMIT BY: / DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) CA.F_k 3,15% '4 14
NAME _ is-n�.�s So '�,
PHONE NUMBER
9YO—a _71, a
ADDRESS
SUBDIVISION NAME
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Ky c.
LOT #
a 3
DIRECTIONS TO SITE
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DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
3
TYPE FACILITY
NUMBER BEDROOMS
NUMBER PEOPLE
SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING i LA_n=-x =A
DATE REQUESTED ��c�/d3 INFORMATION TAKEN BY i-5`' 4—
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
`HOUSE I7 MOBILE HOME BUSINESS ❑
`• House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS N0. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
-GARBAGE'DISPOSAL UNIT'. YES' 0 NO ❑,.�_ Three Bedroom House 900 Gal; 900 Sq. Ft.
AUTO. DISHWASHER YES Q - NO Q . Four Bedroom House 1000',Ga1: 1200 Sq. Ft.,.
"AUTO.: WASH. MACHINE YES 0-- NO ❑
SITE SUITABLE YES '[3 NO, ❑
SIZE OF TANK gala
NITRIFICATION FIELD .._ sq. -ft. P
DEPTH OF STONE IN LINES: !- }
WATER SUPPLY:. Individual ❑' Public ❑
IMPROVEMENTS PERMIT BY 'M1 INSTALLED BY 71
CERTIFICATE OF COMPLETION, ;�� ` �' i�•,. , ,
By 1�-� Date
(8/16/73) *Construction ;must co6ply with all other applicable State and local regulations
LOT. AREA
01917,I
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorpt n Sewage Disposal System G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR _ �, DATE i; _s _ PERMIT
LOCATION f lj ,
SUBDIVISION NAME
LOT NO.
HOUSE [ MOBILE HOME 0 BUSINESS p
f `•
NO. BEDROOMS _y NO. BATHROOMS —;:1—
GARBAGE
:GARBAGE DISPOSAL UNIT YES ❑ NO 0—
AUTO. DISHWASHER YES Qom' -'NO ❑
AUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES NO ❑
SIZE OF TANK ?) ,z gal.
NITRIFICATION FIELD is jnrd sq. ft.
DEPTH OF STONE IN LINES: j ,_V%-
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION
BY—
(8/16/73) *Construction must
LOT AREA .J 2_
N° 815
S. R. NO.
a2 SECTION OR BLOCK NO. L
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House 800 Gal. 600 fSq-..
Ft.
Three Bedroom House 900 Gal 900FtFour Bedroom House Gal. 1200 Sq. t
02�
INSTALLED BY CLL- S- .--
'
0"WIL J 62 01 Date 0-//9/77
aply with all other applicable State and local regulations
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